A Pilot Study for Antimicrobial Stewardship Post-Discharge: Avoiding Pitfalls at the Transitions of Care

Barbara Truskolawski, Pharm.D., CashWise Clinic Pharmacy/ ACMC

Background: Antimicrobial stewardship programs (ASP) are well established across the country – predominantly in the inpatient setting. These programs aim at making interventions to ultimately decrease antibiotic resistance and support appropriate antibiotic use including dosing and duration of therapy.

Objectives: The main objectives of this study were to describe the feasibility of expanding ASP and to follow hospitalized patients after discharge and determine its impact on inappropriate antimicrobial therapy 72 hours after inpatient culture data were finalized.

Study Design: This was a prospective cohort study that included all patients discharged on antimicrobial agents with unresulted culture data at hospital discharge between February 3, 2016 and March 2, 2016. These patients were compared to a pre-intervention cohort discharged without any ASP intervention/ follow up between September 18, 2015 and October 18, 2015. Hospital reports were run daily to identify qualifying patients. Once finalized culture data was available, the ASP pharmacist or pharmacy resident would determine regimen appropriateness. Inappropriate antimicrobial therapy was defined as isolation and identification of any organism from available microbiology cultures taken prior to hospital discharge with documented in vitro resistance (or intermediate resistance) to all prescribed outpatient antimicrobial agents. If the ASP pharmacist or pharmacy resident deemed therapy inappropriate after manual chart review, recommendations were made to the on-call infectious disease physician. Criteria for intervention included, but were not limited to: whether the identified organism was a likely pathogen, whether an adequate duration of antimicrobial therapy had been completed. If an intervention was considered necessary by the infectious disease physician, recommendations were then communicated to the provider who had prescribed the outpatient antimicrobial therapy, with questions and follow-up provided via telephone.

Results: 61 patients with culture data finalized after discharge were identified, only 38 of these patients were prescribed oral antimicrobial therapy at discharge and evaluated by the ASP pharmacist. Five (13%) had a suspected pathogen identified as non-susceptible to their prescribed antimicrobial. Therapy modification was accepted for 3 (60%) of 5 patients.

The historical cohort had 63 patients with culture data pending at discharge, 43 of them had antimicrobial therapy prescribed. Five (11 %) patients in this cohort had grown pathogens reported as non-susceptible to their prescribed antimicrobial therapy, resulting in therapy modification by the discharging physician for 1 (20%) of the 5 patients.

Conclusions: This outpatient centered ASP program shows potential at improving appropriate antimicrobial therapy selection and ultimately decreasing antimicrobial resistance. Some limitations of the study include a small sample size, and a narrow definition of inappropriate antimicrobial therapy, which limited the potential interventions that could have been made by the pharmacist. These results should only be hypothesis forming, to potentially guide other institutions who want to implement their own transitional care ASP.